Aesthetic Repair of Small to Medium-Sized Nasal Defects...and of lateral crural strut grafts to support the existing lower lateral cartilages, onlay grafts, alar rim grafts, spreader

Aesthetic Repair of Small to Medium-SizedNasal DefectsAnil R. Shah, M.D.,1 Richard Zoumalan, M.D.,1 and Minas S. Constantinides, M.D.1

ABSTRACT

Reconstruction of small and medium-sized defects of the nose poses a challenge tothe facial plastic surgeon. Flaps for small to medium-sized defects most often are closed insingle-staged procedures as opposed to larger-sized defects. A variety of techniques can beused including secondary intention, primary closure, full-thickness skin grafts, compositegrafts, rhomboid flaps, bilobe flaps, dorsal nasal flaps, island flaps, and inferiorly basedmeliolabial flaps.

KEYWORDS: Nasal defect, bilobe, rhomboid, meliolabial

Reconstruction of small and medium-sized de-fects of the nose poses a challenge to the facial plasticsurgeon. Every Mohs repair is inimitable based on theunique characteristics of the defect itself, diversity in skintypes among patients and even within the nose itself,variability in structural support, comorbidities, and spe-cific patient aesthetic goals.

The delicate cartilaginous architecture of thenose is easily perturbed by tension vectors and woundcontraction. The myriad of local flaps and grafts avail-able to the surgeon, compounded by the specific nu-ances within each technique, can make repair of aseemingly small, simple defect of the nose extraordi-narily complex. Exacerbating these planning dilemmasis the inverse relationship with patient expectations andthe size of the defect, with the highest aesthetic expect-ations reserved for smaller defects. Many of thesepatients seek single-stage procedures with minimaldowntime and a prompt return to their ‘‘former self.’’

Mohs defects of the nose can be classified accord-ing to size. Defects less than 1 cm in diameter areconsidered small. Medium-sized defects are defined asbeing 1 to 1.5 cm, and those larger than 1.5 cm areconsidered large.1 Conceptually, medium-sized defects

are those that can be closed with a single-stage local flap,whereas large defects typically may require multistageprocedures with regional flaps. In small to medium-sizeddefects, the subunit principle also may hold less weightthan in larger ones. In this article, we will describeimportant factors to consider in preoperative planning,as well as the main reconstructive options for small andmedium-sized nasal defects.

PREOPERATIVE PLANNINGDuring the planning stage, the surgeon must considerthe patient’s overall health. Serious comorbidities maypreclude multistage operations. In such patients, aes-thetic outcomes may be sacrificed for patient safety.However, age alone should not affect the surgeon’sdecision. In a group of patients over 80 years old whounderwent nasal reconstruction, Shumrick, Campbell,and Becker had good to excellent cosmetic results and noflap failure.2 Chronic malnutrition, bleeding diatheses,uncontrolled hypertension, smoking, and uncontrolleddiabetes worsen healing and increase the potential forcomplications. Patients should be medically optimized asmuch as possible before the resection/reconstruction.

1New York University School of Medicine, Division of Facial PlasticSurgery, Department of Otolaryngology–Head and Neck Surgery,New York, New York.

Address for correspondence and reprint requests: Anil R. Shah,M.D., Facial Plastic & Reconstructive Surgery, 7 West 51st Street, 6thFloor, New York, NY 10019.

Aesthetic Reconstruction of Head and Neck Defects; Guest Editors,Manoj T. Abraham, M.D., F.A.C.S., Keith E. Blackwell, M.D.

Facial Plast Surg 2008;24:105–119. Copyright # 2008 by ThiemeMedical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel: +1(212) 584-4662.DOI 10.1055/s-2007-1021893. ISSN 0736-6825.

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Our preoperative planning, in concert with the Mohssurgeons, includes cessation of smoking 3 weeks prior toexcision/reconstruction. If the patient has not quit by thetime of excision, he or she is advised regarding potentialvascular limitations and complications of their recon-struction.

Preoperative assessment should consist of diligentexamination of both the defect itself and the surroundingtissues. The location and depth of the defect, along withthe destruction of normal skin structures, should benoted. Attention should also be paid to the potentialvascularity of the floor of the defect. This is especiallyimportant in assessing the suitability of the bed for apotential skin graft.

The subunit principle is mentioned often in repairof nasal defects. Millard divided the face into facialaesthetic subunits and advocated the use of subunits innasal reconstruction.3 Burget and Menick further de-fined the nasal aesthetic subunits (Fig. 1).4 The recon-structive principle utilizing aesthetic subunits promotesthe removal of an entire subunit if 50% or more is absent.However, by removing the remaining half or less of asubunit, the surgeon may unnecessarily resect healthytissue, which would consequently require a larger cover-age area. Rohrich and colleagues suggested that theexcision of healthy tissue is unnecessary if a satisfactoryscar can be placed within the borders of a subunit.5

Burget’s concept of nasal skin types is perhapsmore significant in nasal reconstruction of small tomedium defects than aesthetic subunits. The surgeonmust examine the nasal skin and carefully palpate toadequately plan for the most optimal skin match.5 Theupper half of the nose (zone I), which includes the

dorsum and nasal sidewall, has very loose, thin, com-pliant skin. In contrast, the nasal tip (zone II) has skinthat is 3-mm thick or more and is covered with pits,which are ducts of the subdermal sebaceous glands. Thisskin is thick, sebaceous, and unforgiving. Because itso readily reforms its previous shape, it is difficult tocontour and reconstruct. Its round convex contour alsomakes it a difficult area to repair. Zone III is located atthe region of the tip halfway down the infratip lobule,where the skin again becomes thin and nonsebaceous.Zone III also extends along the alar margins to includethe soft triangle facets and columella in a 4-mm-widestrip. Typically, the skin of zone III is fixed to theunderlying cartilages and has scant fibrofatty tissue. Insome patients, an intracrural groove can be seen, wherethe contours of the alar cartilages create a vertical line ofshadow (Fig. 2).6

The skin color, texture, and porosity of the nasalskin surrounding the nasal defect will play a critical rolein ultimately determining the type of reconstruction thatwill appear most natural. Preoperative planning shouldalso include analysis of previous scars and areas ofradiation. A history of nasal tip cyanosis in response tocold temperatures may indicate vascular compromise.However, typically the blood supply to the nose isabundant, with branches from both the external carotid(facial and angular artery) and the internal carotid(ophthalmic artery).

Cartilaginous support to the nasal tip and externaland internal valves should be assessed preoperatively.Even minimally weak external or internal nasal valves are

Figure 1 Classically there are nine nasal subunits with

some texts describing the root as an additional subunit of

the nose.

Figure 2 The three zones of nasal skin types have widely

divergent differences in skin thickness and mobility.

106 FACIAL PLASTICS SURGERY/VOLUME 24, NUMBER 1 2008

susceptible to further compromise after Mohs repair.Unfortunately, there is no simple solution to repair anddiagnose potential nasal valve incompetence. Some po-tential solutions include placement of alar batten graftsand of lateral crural strut grafts to support the existinglower lateral cartilages, onlay grafts, alar rim grafts,spreader grafts, and upper lateral cartilage splay grafts.A working knowledge of aesthetic and functional rhi-noplasty is required to determine which graft to placeand how.

Avoidance of alar displacement is another impor-tant assessment, as minimal vectors of wound tensioncan cause unwanted alar retraction.7 A surgeon must beable to accurately predict how these forces will affect theposition of the ala.

Preoperative consultation plays an important rolein managing the patient’s expectations of aesthetic out-come. Ideally, preoperative photography is performedprior to Mohs resection to allow for a better concept ofthe patient’s nose. Nasal and alar symmetry must beassessed, documented, and discussed with the patient toprevent any misunderstandings after surgery. As in anyfacial plastic surgery procedure, patient expectationsshould be tempered and a typical recovery course out-lined. Patients must be counseled on the major risks ofreconstructive failure including tissue necrosis, scar for-mation, infection, hematoma, and wound contraction,any of which may cause disfiguring asymmetry or adverseeffects on nasal airflow.

TIMING OF REPAIRReconstruction is offered when the defect is deemedunsuitable to heal by secondary intention. Reconstruc-tive procedures help prevent complications of woundcontracture. Additionally, for patients who are uncom-fortable with open wounds on their face, reconstructionoffers immediate coverage and decreases time of healing.In almost all our patients, reconstruction occurs imme-diately after Mohs surgery. However, in instances whenimmediate reconstruction is not an option, coverageof the defect is important to prevent desiccation ofthe wound. Increasing time to reconstruct may limitsome reconstructive options at a future date, includingthe use of full-thickness skin grafts.

SECONDARY INTENTIONSecondary intention is ideally utilized in wounds thatare small, shallow, and on concave surfaces. In addi-tion, wounds less than 1 cm in diameter, less than 4 to5 mm in depth, and greater than 5 to 6 mm in distancefrom the mobile alar margin will often heal withexcellent aesthetic results.7 In particular, the superficialareas of the alar groove, a concave area, can healexceptionally well. If a defect of the alar groove is

deep enough to extend to the subcutaneous fat andallowed to heal by secondary intention, it may result ina depressed scar, retraction of the alar rim, or nasalvalve collapse.8 The lateral sidewall of the nose, espe-cially near the medial canthus, also heals well withsecondary intention. The tight, thin skin in this areawith strong underlying bony support fights contractionwell without distortion of the surrounding face duringsecondary intention healing.

Wounds should be cleaned twice daily to removefibrinous debris and covered with ointment to allow for aclean moist wound. Reepthelialization begins within24 hours at a rate of 0.25 to 0.5 mm per day. Granulationtissue will begin to form within the first 72 hours. Bothof these processes allow for wound contracture to start5 days after creation the defect. Patients should becounseled that wounds take weeks to months to healdepending on the size of the defect, wound care applied,and individual physiological healing capabilities.

Frequent weekly follow-up to ensure appropriatewound healing is prudent. Some patients benefit fromexternal or internal bolsters to prevent irregularities inwound contracture. An internal nasal splint is effective indefects of the alar region when concern over alar retrac-tion and irregular wound healing may occur (Fig. 3). Anexternal bolster is applied to the dorsal sidewall or medialcanthus to help reduce the incidence of webbing.

Dermabrasion may be used after 4 weeks if minorcontour irregularities exist (Fig. 4A,B). However, largedistortions may require excision and replacement of thecontracted tissue and may be much more difficult toreconstruct than the initial defect.

Some small (< 1 cm) nasal defects that extend tosubcutaneous fat can be closed with a combination ofpartial primary closure and secondary intention. If thedefect is found on the nasal alar groove, two subcuta-neous absorbable sutures can be placed in the center ofthe defect along the direction of the alar groove. No

Figure 3 Intranasal splints can help bolster the nostril and

prevent nasal retraction and contour irregularities during

secondary intention. The material used in intranasal splints

should be stiff enough to resist forces of scar contracture.

(Photograph provided by Anil R. Shah, M.D.)

AESTHETIC REPAIR OF SMALL TO MEDIUM-SIZED NASAL DEFECTS/SHAH ET AL 107

superficial sutures are needed, and the wound will healby secondary intention.9

PRIMARY CLOSUREIn the upper half of the nose, primary closure is possiblewith small defects. In this area, the skin is usually thinand compliant. In contrast, the skin of the nasal tip ofthe nose cannot be readily closed primarily due to a lackof laxity.

To avoid dog-ear deformity, most wounds neces-sitate a length:width ratio of at least 3:1. However, oncethe surgeon excises extra tissue, some reconstructiveoptions may be lost. A more conservative approach isto undermine the wound and place several large keysutures. If it appears that alar margin and tip distortionwill occur after primary closure, an alternative recon-structive technique can be performed without compro-mise. If the closure allows for an acceptable aestheticresult, excision of the dog-ear can then takes place. Thedog-ear can be excised to be hidden along nasal subunitsor lines of maximal extensibility for further camouflage.In areas where extra closure length is limited, thesurgeon can create an M or W at the end of the defectrather leaving a simple fusiform. Eversion is especiallyimportant in thicker, sebaceous skin due to increasedskin rigidity.10

Defects of the caudal and middle third of thedorsum will rotate the tip cephallically if repaired in atransverse fashion. This may be aesthetically desirable insome patients with senile tip ptosis. A vertical closurewill limit nasal tip rotation. Glabellar defects should beclosed horizontally to match the rhytids produced bythe procerus muscle contraction. Certain defects may beamenable to vertical oblique closure, matching the actionof the corrugators. If not enough skin is available and thepatient has a wide and/or large dorsum, reductionrhinoplasty can be performed.11 Dorsal reduction canbe performed either through the wound or via a tradi-tional rhinoplasty approach.

SKIN GRAFTSAlthough a split-thickness skin graft is an option, it israrely a good one. Split-thickness skin grafts avidly con-tract and undergo thinning and hypopigmentation, re-sulting in unsightly cosmetic appearances. Although theyallow for coverage of a large area, their use is mostlylimited to biological dressings. They can play a role in thepatient who has a virulent neoplasm and will likely requirefurther resection before a definitive reconstruction.

A full-thickness skin graft is a much more aes-thetically viable option than a split-thickness skin graft.A full-thickness skin graft is a good option if the wound

Figure 4 (A, B). This patient had a small, shallow nasal defect. However, the lesion was located 4 mm from the alar margin

and on the convex aspect of the ala. Despite this, the patient healed without alar retraction 4 weeks after her Mohs procedure

due to strong lower lateral cartilages and alar splinting. She will require a dermabrasion procedure to improve contour

irregularities. (Photograph provided by Anil R. Shah, M.D.)


is not amenable to primary closure, closure by secondaryintention, or an uncomplicated flap repair. Comparedwith split-thickness skin grafts, they contract much lessand are therefore less likely to result in alar retraction.This type of graft also maintains its color and texturebetter. The graft must be chosen from an area of thebody with similar color and texture. Although thesegrafts may perform well, random-pattern cutaneous flapstypically offer better aesthetic results. Full-thickness skingrafts work best for shallow defects as the grafts arethinned to maximize their survival during placement.12

The vascular demands for full-thickness skingrafts exceed those of split-thickness skin grafts. Duringthe first 24 hours, they survive based on plasma imbibi-tion. In the second 24 hours, vascular inoculation feedsthe graft. On day 3, capillary in-growth begins.13

The donor site must be carefully chosen. Todecrease the chance of confusion of recurrence, donorskin must not include any color abnormalities or malig-nancies. Common donor sites include the preauricular,postauricular, supraclavicular, and clavicular areas. Somesurgeons also use the neck, nasolabial folds, eyelids, andupper extremities as potential donor sources.14 If usedfor sidewall defects instead of a local flap, postauricularskin is a great match for color, skin thickness, andtexture. If the defect is located closer to the medialcanthus, the full-thickness skin graft becomes a betteroption but is still unfavorable compared with a localflap.1 Many surgeons prefer the conchal bowl skin as agood match for tip or ala defects. For these sites,harvesting the underlying perichondrium with the skinprovides for a thicker graft with enhanced ability torapidly develop a new blood supply from the recipientsite. Forehead full-thickness skin grafts can be used incertain cases and have been found to have good func-tional and cosmetic outcome owing to excellent tissuematch.15

The success of the graft’s ‘‘take’’ depends onseveral factors. Vascularity of the defect is crucial anddependent on underlying viable muscle, fascia, perichon-drium, or periosteum. The graft also should be suturedto the underlying tissue using absorbable sutures so thata hint of concavity exists.16 A balance of meticuloushemostasis and prevention of cautery damage to theunderlying vascularity of the wound bed must beexercised. Marginal quilting sutures will help collapsepotential dead space, and central quilting sutures avoidlateral motion. A stent dressing allows pressurebetween graft and bed to improve vascularization tothe graft.

Full-thickness skin grafts on the nasal tip are atempting choice, but several reconstructive principlesshould be kept in mind. Nasal subunit technique shouldbe used to prevent a patch effect. Less thinning is neededon full-thickness skin grafts than when used in the upperone third of the nose.

COMPOSITE GRAFTSComposite grafts contain two or more tissue layers.Due to the metabolic demand of the large bulk oftissue, they heal with great difficulty and are limitedto defects less than 1 cm in size.15 This type of graftrequires a nonsmoking patient without systemic ill-nesses or prior irradiation that would compromiserevascularization.

Composite grafts have been used for small(< 1 cm) full-thickness defects of the columella, alarmargin, and soft tissue triangle (Fig. 5). The auricularconcha is an excellent source for a composite graft. It iswell suited for defects in the columella and alar carti-lages. Other donor sites include the helix, antihelix,tragus, and antitragus. All these areas contain tight,thin skin overlying cartilage without much subcutaneousfat, making them good donor sites.

Alar wounds, especially those that approach thesuperior aspect of the ala, are prone to notching andretracting. If designed well, a composite graft can pro-vide structural integrity at the nasal valve. It can alsoproduce the same smooth contour that exists at itsauricular donor site. Some authors dismiss compositegrafts as an option for alar reconstruction, arguing thatcomposite grafts heal with a shiny, imperfect colormatch. In addition, alar notching, if it occurs, can beseverely disfiguring and difficult to correct.1

In an effort to decrease donor site morbidity froman auricular composite graft, Burm advocates the use of amastoid partial composite graft for reconstruction of thenasal tip including the columella and soft tissue triangle.This is a graft consisting of full-thickness skin periph-erally and fascia-fat tissues underneath the skin centrally.The mastoid skin is thicker and more rigid than auricularskin, which makes it less likely to shrink. On the otherhand, it is thinner than forehead skin, so it is easier tofold for reshaping the nostril rim.17

Harvesting auricular grafts requires maintenanceof the tight, thin skin to the overlying cartilage. Theauthors advocate injecting local anesthetic agents peri-pheral to the harvest site to maintain tight adherence ofskin and cartilage. In addition, one or two central suturesmay help prevent disruption of the cartilage and skin.Finally, trimming the underlying cartilage to allow for aslight excess of skin to cartilage can lead to increaseduptake of composite grafts.

Composite grafts should be inset with interruptedsutures using as few sutures as possible to enable moreabundant vessel growth. If the graft is small, no suturesare needed for the cartilage, and only skin 5–0 poly-propylene sutures are necessary. Some advocate the useof stabilizing struts for composite grafts at the alar rim.These are cartilaginous extensions that are placed underskin adjacent to the graft using tongue-in-groove tech-nique.18 Preoperative corticosteroids have shown im-proved survival of composite grafts.19 Ice compresses


Figure 5 (A) Patient is shown with an alar defect secondary to Mohs procedure. She had a nasal turndown flap (B) with alar

retraction near the soft tissue triangle of the nose. A subsequent procedure was performed with an auricular composite graft in

the soft tissue triangle to improve her alar retraction. (Photograph provided by Minas Constantinides, M.D.)


for the first 3 days to composite grafts have also shown toimprove graft survival.20

RHOMBOID FLAP (TRANSPOSITION FLAP)The rhomboid flap is best suited for reconstruction ofthe lateral nasal sidewall and glabellar areas.21 In areasnear the tip and alar margin, its tension vectors can causeserious distortion. In the sidewall and glabellar areas, therhomboid flap gives the opportunity to move tissue andreorient tension vectors. Rhomboid flaps are local innature with minimal impact on the movement of distalskin (Fig. 6A,B).22

Limberg originally designed the rhomboid flap.In his design, the location of maximal tension is at theclosure point of the donor flap defect.23Dufourmenteladded a modification that rotates the axis of the donorsite by 30 degrees.24 Webster et al added a furthermodification of the flap, which he calls the ‘‘30-degreetransposition flap.’’25 In all versions of the rhomboidflap, as long as the flap and the tissue surrounding theflap are adequately undermined, there should be littleto no tension on the flap. The Dufourmentel flap makesthe closure of the donor site much easier and decreasestension there. However, this is at the expense of in-creased tension around the transposed flap’s borders. If

possible, the line of closure of the donor site, which isusually the area of maximal tension, must be placed in aline of maximal extensibility of the face. It also must beplaced in an area that will produce the least distortion onthe face. Areas that have high risk of distortion are thenasal alae, medial canthus, and oral commissure.

Rhomboid flaps can move smoothly into positionwhen there is adequate laxity of the donor area. Themathematical analysis of rhomboid flaps by Koss andBullock concluded that the rhomboid flap allows forexactly the same area of tissue coverage for the defectfor which it is designed.26 However, skin allows forflexibility, and the areas need not be anatomically exact.Because the skin is elastic in nature, rhomboid flaps canbe used for defects that are not rhomboid in nature.Rhomboid flaps may even be combined with nasolabialflaps for the repair of lateral nasal defects.26

BILOBED FLAPThe bilobed flap is a double transposition flap firstdescribed by Esser to reconstruct nasal tip defects.28 Itis a random pattern, single-stage flap, lacking a large-caliber vessel in its base. A bilobed flap uses two adjacentlobes/flaps that are rotated around a pivot point. Theprimary lobe, usually the same size as the defect, is used

Figure 6 (A, B) Patient with lateral nasal wall defect bordering cheek subunit. A rhomboid flap was designed and hidden

within the nasolabial fold to close this defect. (Photograph provided by Anil R. Shah, M.D.)


Figure 7 (A–C) A medium-sized defect involving the left supra-alar crease and left nasal sidewall. A medially based flap was

chosen for this case because a laterally based flap would have limited rotation secondary to pivotal restraint at the medial

canthus. Limitation of nostril movement is essential in the planning of bilobe flaps. (Photograph provided by Anil R. Shah, M.D.)


to restore the defect. The secondary lobe is used to repairthe donor site of the primary lobe. The donor site of thesecondary lobe is closed primarily. Flaps based laterallyon the sidewall of the nose are best for defects near thenasal tip, and medially based flaps are better for repair oflateral alar defects.27 Flaps based laterally may be limitedby tension at the medial canthus and may need to bemedially based to facilitate closure (Fig. 7A–E).

The flap’s design is highly flexible. Esser, in hisinitial description, stated that the angle of tissue transferhad to be 90 degrees.28 However, subsequent authorshave found that the angle can be decreased significantlyto suit the situation.29 Perhaps the most significantmodification was by Zitelli27, who adjusted the rota-tional angle to 50 degrees each, decreasing the bucklingaround the pivot point and the distal distortion fromprevious bilobed flap designs.

The bilobed flap is the reconstruction of choicefor most small to medium-sized defects of the lowerthird of the nose, especially the lateral tip, supratip, or alanear the tip. Because it takes skin from adjacent areas, itprovides excellent color match and is relatively free fromdistortion.1 Ideal patient candidates for the bilobe flaphave thin and mobile skin. Thick, sebaceous skin has lessmobility for transfer and an increased risk of complica-tions such as necrosis, trapdoor deformity, and depressedscars. The lax donor skin of the upper nose limits the flapto areas less than 1.5 cm.30

To ensure a safe blood supply, the width of thesecond flap should approach the width of the first flap.Undersizing the primary or secondary lobe may result inincreased tension, scarring, and distortion. Oversizingmay lead to trapdoor deformity and uneven contours. Incases of thick donor site skin, the primary lobe should bethe same size as the defect due to limited ability tostretch the primary lobe.

The length of the bilobe flap also plays a signifi-cant role in its design. Cho and Kim used fresh cadaversto demonstrate that the primary lobe in a bilobe shouldbe designed with a 10% longer flap than the defect todecrease the incidence of alar distortion.31 Zitelli’s rec-ommendations for use of a longer primary lobe arelimited to instances when there is skin that is too tightfor rotation of the flaps and closure of the secondary flapdonor site. This type of situation exists at the immobileskin of the inner canthus, where there is little looseskin.32

The thickness of the bilobe flap may vary depend-ing on the defect and location within the flap. At thebase of the flap, it is important to lift the flap in asupraperichondrial plane to maximize blood supply andallow for venous and lymphatic outflow from the flap. Asuperficial layer of elevation at the bilobe flap’s base riskspincushioning to the flap. The distal edge of the flap mayneed to be thinned to create a better match with theremaining nose skin. A flap that is too thick may push

the unsupported alar rim inferiorly. This is especiallytrue at distal flaps near the alar rim. However, over-zealously thinning the flap may compromise blood flowto its distal part. To prevent this, the surgeon may chooseto instead deepen the defect when possible.

When designing the bilobe flap, the location ofthe dog-ear can also effect alar displacement. Placementof the dog-ear within the supra-alar crease is preferredrather than in the convexity of the nasal ala.21 Dog-eardesigns further from the alar rim may lead to less alardisplacement as well. Dog-ears within the supra-alarcrease also lead to less visible scars.

The secondary lobe may play a larger role in alardisplacement than previously thought in laterally basedbilobe flaps.33 The secondary lobe may exert woundvector forces, which may influence alar displacement,which was recently suggested by a fresh cadaveric study.Vector alignment of the secondary lobe perpendicular tothe alar margin decreased the amount of alar displace-ment, and alignment of the secondary lobe 45 degrees tothe nostril margin created alar retraction (Figs. 8A,B and9A, B).

DORSAL NASAL FLAP/RIEGER FLAP(ROTATIONAL FLAP)The dorsal nasal flap can be used for medium-sizeddefects of the nose. This flap was originally describedby Rieger35 and has been subsequently modified.34 Dueto its large size, the glabellar flap has the potential risksof distortion and flap necrosis. The flap recruits skinfrom the more mobile glabella and transfers it caudally tothe less mobile tip by incorporating a V to Y advance-ment cephalically. Thus, a long incision is created fromthe glabella to the nasal tip with undermining as far wideas midcheek (Fig. 10A–C).

To decrease the likelihood of tension on themedial canthus or the alar margin, the arc of rotationof the flap can be elongated. Equally important in thedesign of the dorsal nasal flap is extension of the leadingedge along the primary defect, which is distinct from atraditional rotation flap design. The modification min-imizes the influence of pivotal restraint on the flap. Themobility of the flap is dramatically enhanced with asignificant back cut in the area of the glabella. Theback cut can be extended to the area of the medialcanthus, and it produces a flap that is mobile becauseof a narrow pedicle.35

Once the flap has been elevated, broad under-mining occurs laterally. Deep sutures to stabilize the flapto the underlying periosteum will help minimize un-wanted vector pulls. Buried vertical mattress sutures canalso help anchor the flap.34,35 In the dorsum and supratipregions, this flap causes less local distortion than thebilobed flap. Due to risk of alar retraction, it should beused cautiously in unilateral alar rim or dome defects.


In certain instances, the authors have designedthis flap within the nasal tip subunit by removing thedog-ear at the lateral portion of the nasal tip rather thanwithin it. Improved shadowing camouflages scars withthis design and improves wound contraction, withless nostril distortion. However, given its tension canpull the tip dorsally, it can cause symmetrical upward tiprotation.1

SINGLE-STAGE MELOLABIAL FLAPWith a single stage, an inferiorly based melolabial flapcan provide an excellent option for full-thickness, me-dium to large alar defects. It is most ideal for defects inthe lateral alae or in the lateral alar groove.36 Alsoreferred to as the nasolabial flap, it consists of cheektissue surrounding the melolabial crease from the ala tothe oral commissure.

The melolabial flap can be performed in one ortwo stages. The two-staged flap has the advantage ofbetter creation of the alar crease. The single-stage flapcan blunt the alar groove.39 However, not all patients

are amenable to multiple stages, and other optionsshould be available. An advantage of the flap is thatthe donor site is well camouflaged in the melolabialcrease. Drawbacks of the flap are the risks of pincush-ioning and trapdoor formation when performed as asingle stage.37

The technique involves a long incision in themelolabial fold. Pivotal restraint shortens the rotatedflap, and this must be taken into account when designingthe length of the flap. However, oversizing the flap canlead to trapdoor deformity. The flap is widely under-mined in the central cheek to allow for rotation andtransposition. Deep tacking sutures in the nasofacialsulcus are used to create adequate concavity. Dog-eardeformities are excised at the area superior to the surgicaldefect and the melolabial groove. Buried sutures are usedto anchor the flap, and incisions are closed with runningsutures. Revision procedures can be performed in thefuture to contour the alar groove.

For columella reconstruction, unilateral or pairednasolabial flaps can be used for reconstruction. Totalcolumellar reconstruction is well performed with pair

Figure 8 (A, B) In a laterally based bilobed flap, the secondary lobe should be designed perpendicular to the nostril to account

for wound contracture.


flaps anchored to a cartilage columella strut graft. Thecolumella strut must be sturdier than conchal cartilage.Septal and costal cartilage grafts are ideal.

For alar defects from 8 mm to 2 cm, the use of asuperiorly based nasolabial flap may be preferred. Thisflap usually requires a second stage. Supra-alar andposterior alar defects can be performed with a singlestage.1

ISLAND FLAPS (V TO Y FLAPS)The island pedicle flap is also known as the V-Y flap.It uses an underlying subcutaneous pedicle to advancesoft tissue into a defect while maintaining a healthyblood supply from its former location. The pediclealso includes venous and lymphatic drainage overmost of its length.38 In the nasal region, it should beconsidered a musculocutaneus flap. It is a good flapfor reconstruction of small to medium defects of thealar crease (Fig. 11A–D). It has also been used in

defects of the sidewall, dorsum, and glabella.39 Forsmall defects of the nasal tip, the nasalis myocutaneousisland pedicle flap may be used to advance tissueinferiorly. This flap is a superiorly based flap from thenasal dorsum.40

Key to the use of a pedicle is an understanding ofthe model of axial and perforating vessels. Located in thesubcutis and superficial fascia, axial vessels lie in ahorizontal network. The vessels that feed the axialvessels are the vertical perforators that are located withinthe muscle. The blood supplying the skin comes fromsmaller subdermal vessels that are perforators from theaxial vessels. Undermining the subcutaneous fat willpreserve some of the axial vessels. Thinning of the flapwill sacrifice more of these vessels and make the flapmore reliable on the subdermal plexus.41,42

An incision is made through the dermis, andblunt scissor dissection is used to dissect the flap fromits attachments to determine where the flap is beingtethered. The incision is carried to the subcutaneous fat,

Figure 9 (A, B) In a laterally based bilobed flap, if the secondary lobe is designed with an acute angle in relation to the plane of

the nostril, alar retraction may occur postoperatively.


Figure 10 (A–C) A medium-sized defect that was deemed too large for a bilobed flap based on the location of the defect and

the anticipated changes in nostril symmetry. A Rieger flap was designed within the nasal tip subunit and along the dorsal

subunit to improve shadowing of scars postoperatively. (Photograph provided by Anil R. Shah, M.D.)


Figure 11 (A–C) Patient with a defect at the alar crease. An island flap was designed in part due to patient desire to avoid a

pedicled flap. (Photograph provided by Anil R. Shah, M.D.)


thus separating the island’s dermis and epidermis fromthe surrounding tissue. The pedicle is subcutaneous andis located inferior to or underneath the flap, and it may ormay not include muscle. To improve mobility andsurvival, the length should be at least three times thediameter of the defect. When one increases the flaplength, there is greater potential surface area of theunderlying pedicle. Thicker tissue under the flap allowsfor more mobility because more of the pedicle can benarrowed for movement.43

The V-Y flap allows the transfer of tissue over adistance and diminishes tension. It also does not leavedog-ears, which may require subsequent management.For defects of the ala and lateral surfaces of the nose, theV-Y flap can be taken from the nasolabial fold or fromthe cheek. Some surgeons advocate tunneling the flapsubcutaneously to reach the alar defect. The flap mayalso be slid beneath the ala to close a defect. Theresulting scar is placed in the nasolabial fold. Defectsof the middorsum can be closed with bilateral V-Y flapsfrom the lateral nose and cheek. Midline defects of thetip, dorsum, and glabella can be managed with midlineflaps.4

POSTOPERATIVE CAREFollowing the reconstructive procedure, a generousamount of antibacterial ointment is placed on thesuture line. Postoperative oral antibiotics are givento patients with cartilage grafts, diabetics, immuno-compromised patients, and smokers. A nonadhesivedressing is place over the area and secured using papertape for the first 24 hours. Using cotton tip applicatorssoaked with saline, patients are taught to gentlyclean the wound and to reapply ointment three timesa day. Sutures are removed on postoperative day 7.They are instructed to keep out of the sun, use sunscreenwith a sun protection factor of at least 30 for thefollowing year, and wear a protective hat wheneverpossible.

Patients are followed closely postoperatively.Unless refused by the patient, all scars are dermabraded6 to 8 weeks postoperatively to improve scar cosmesis.The authors prefer the use of diamond burrs on low-speed rpm for precise removal of scar to the level ofthe papillary dermis. Rohrich et al promote primarydermabrasion or laser resurfacing at the wound marginsin almost every nasal reconstruction. Some cases mayrequire revision secondary dermabrasion for optimalcontour.1

CONCLUSIONThe reconstructive options for small and medium-sizednasal defects are many. Within each reconstructiveoption, there are multiple planning decisions that must

be made. Success in reconstruction lies in preoperativeplanning and a strategy that will predict the dynamicnature of soft tissue and its effects on underlying archi-tecture.

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Aesthetic Repair of Small to Medium-Sized Nasal Defects...and of lateral crural strut grafts to support the existing lower lateral cartilages, onlay grafts, alar rim grafts, spreader